Technology Services and Solutions: Have Lessons Been Learned?

TSS failed to recognize significant warning signs from staff and CalEQRO reports in its effort to link two systems from separate vendors. As a result, the system was not able to process Medi-Cal claims. Furthermore, the system did not satisfy federal privacy and state reporting requirements. This led to delays in billing, unanticipated additional work for County staff, and finally, a redesign of the system.

TSS did not follow project management best practices. There was no requirement that the project managers need project management experience. TSS used multiple project managers, none of whom had responsibility for the overall project. This complicated coordination and decision making.

TSS did not have a process in place to prove that the new EHR system would work prior to deployment. TSS did not adequately test the integration of the HealthLink and Netsmart system before releasing it to Behavioral Health clinics. Management placed primary emphasis on meeting the project schedule rather than supporting a gradual system rollout. This led to halting the submission of Medi-Cal claims, which threatened the loss of tens of millions of dollars.

TSS and Behavioral Health were not sufficiently engaged in the contract negotiations with Netsmart for the May 2019 agreement. Lacking detailed input from project management on resources and scheduling for the analysis and training work, Procurement eliminated these tasks from the agreement. This elimination contributed to delays and required the subsequent negotiation of three additional agreements to address these shortcomings.

29 REQUIRED RESPONSES ......................................................................................................... APPENDIX: Project Manager Responsibilities ....................................................................... GLOSSARY AND ABBREVIATIONS 42 CFR Part 2 A section of the Code of Federal Regulations that requires substance use disorder treatment providers to observe privacy and confidentiality restrictions with respect to patient records. Behavioral Health Behavioral Health Services, often referred to as Behavioral Health, is the department within the County of Santa Clara Health System that works with clients experiencing mental health and behavioral issues. CalEQRO California External Quality Review Organization performs an annual evaluation of every county’s behavioral health services department. Contract Provider An organization that contracts with the County to provide behavioral health services CSI Client and Service Information is a system that generates reports required by the State of California for measuring timeliness of mental health care. EHR Electronic Health Record is a digital version of a patient’s paper medical record. Governance Gates Checklist A Technology Services and Solutions project management form that divides a project into distinct stages Health System The County of Santa Clara Health System includes the Behavioral Health Services Department, Public Health Department, Santa Clara Valley Medical Center hospital and clinics, O'Connor Hospital, St. Louise Regional Hospital, Emergency Medical Services Agency, Custody Health Services Department, and Valley Health Plan. HealthLink An electronic health record system, developed by Epic Systems Corporation and used by the County of Santa Clara Health System HL7 A network protocol used to electronically transmit medical information Hospital Finance A department within the Health System that manages patient billing and other financial responsibilities HSR A Health Service Representative is a clerical staff member who registers clients and schedules appointments. Medi-Cal Medi-Cal is California’s Medicaid program, which pays for a variety of medical services for children and adults with limited income and resources. MHSA The Mental Health Services Act was passed by California voters in 2004 to expand services to county mental health systems. Netsmart Netsmart Technologies, Inc. develops electronic health record systems for behavioral health organizations. Procurement The County department responsible for purchasing goods and related services Project Management Center of Excellence A Technology Services and Solutions office that administers the Governance Gates Checklist ProviderConnect A Netsmart module that allows contract providers to securely transmit medical data to the County through a web interface ProviderConnect Enterprise A Netsmart module that allows contract providers to securely transmit medical records to the County through a programmatic interface RFP A Request for Proposals is a document that solicits bids from vendors for County services. Short-Doyle Act The Short-Doyle Act established a county- based, rather than state-based, behavioral health system. It includes requirements that must be followed when submitting claims to Medi-Cal. SUTS Substance Use Treatment Services is the division of the Behavioral Health Services Department that provides alcohol and drug treatment services. TSS Technology Services and Solutions is the County of Santa Clara information technology (IT) department. Uni/Care The software system used by Behavioral Health Services prior to 2018 INTRODUCTION Complex software projects are notorious for encountering delays and cost overruns. However, sophisticated development teams can overcome these challenges by using software engineering best practices, following established project management frameworks, and continually learning lessons from past projects. The 2021 Civil Grand Jury of Santa Clara County (Civil Grand Jury) investigated one troubled project to understand what went wrong. This report looks at one particular example as a case study. In 2018, the County launched a customized electronic health record (EHR) system for clinics in the Behavioral Health Services Department (Behavioral Health). Development of this system was overseen by Technology Services and Solutions (TSS), the County's information technology department, which is responsible for managing the County’s computer hardware, software, and network infrastructure. The EHR system was intended to modernize clinical record-keeping, patient billing, and reporting for State and County oversight. The County Health System operates the County-owned hospitals and clinics. In 2013, most of the Health System departments started using an EHR system named HealthLink (made by Epic Systems Corporation) to keep track of patient healthcare records. However, HealthLink did not fully meet the needs of one Health System department, Behavioral Health. Behavioral Health is the department that works with clients experiencing mental health or substance use issues. Clients experiencing mild or moderate symptoms can receive support from the County’s primary care clinics, but clients with severe issues are seen at clinics that specialize in behavioral health. The 14 Behavioral Health specialty clinics operated by the County serve less than 20% of the demand for services. Consequently, the County contracts with non-profit providers for additional clinics to provide more than 80% of behavioral health services.1 Most behavioral health services are covered by Medi-Cal, which is California’s public health insurance program that provides health care coverage to low-income individuals and families. Medi-Cal contributes $100 million to $120 million in annual revenue to Behavioral Health and has specific claims requirements for behavioral health services. Because these claims requirements were not supported by HealthLink, TSS selected Netsmart, a vendor specializing in behavioral 1 Behavioral Health Concepts (CalEQRO), “FY2020-21 Medi-Cal Specialty Mental Health External Quality Review: Santa Clara MHP Final Report,” p. 46, January 14, 2021, https://www.caleqro.com/data/MH/Reports%20and%20Summaries/Prior%20Years%20Reports%20and%20Summa ries/Fiscal%20Year%202020- 2021%20Reports/MHP%20Reports/Santa%20Clara%20MHP%20EQRO%20Final%20FY20-21%2003.24.21.pdf. health services, to provide the billing software. As discussed later in this report, linking HealthLink with Netsmart complicated the project. After almost two years of planning and development, the new EHR system was launched in February 2018. However, once the system became operational, the County detected numerous errors in the pending behavioral health Medi-Cal claims. The County halted the billing component of the new system and faced the crisis of potentially losing millions in reimbursements. Medi-Cal requires claims to be submitted within one year from the date of service, and it was unclear how long it would take to fix the billing problems. Management formed a billing remediation team to correct the problems and managed to resolve most of the billing issues before the Medi-Cal deadlines expired. Nevertheless, such an intensive effort on individual claims was unsustainable, and by late 2018 the County decided to redesign the EHR system. There are a number of important lessons to be learned from this project. After a more detailed discussion of the history of this multiyear project, several areas are identified as the root causes of the troubles encountered. These include insufficient attention to the initial analysis and feasibility of the project, a failure to follow industry best practices for project management, and the lack of testing necessary to ensure a successful deployment. In addition, miscommunication among County departments led to problems while negotiating amendments to the original Netsmart agreement. Finally, there are concerns that the current phase of the project lacks sufficient planning and project management controls. In this report, the Civil Grand Jury provides 12